Statement of Consumer Dispute

Carefully read all instructions and complete the form ​in full​ before submitting. 
Incomplete forms may delay the timely settlement of your dispute. 
We must receive this form back within 10 business days in order to provide you a provisional credit. 

Section One – Your Information 

Name  Contact Number 
     

Account Number  Email Address 

     

Section Two – About Your Dispute 

Transaction Information 

Amount ($)  : 

Transaction Date & Time  : 

Merchant Name  : 

Merchant Address (including ZIP and  : 

names of any relevant buildings) 

Instructions: 

1. Check only one of the following which best describes your dispute. 

2. Please be sure to provide all requested information/evidence, we will be unable to process your 
dispute unless all of the required information/documentation is provided.  

3. Please provide as much detail as possible about your dispute in the additional comments section. 

4. Please provide all required documentation, along with this form, in your email reply. 

 
 
 
 
 
 
 
 
 
 

     
Form: ​Statement of Consumer Dispute  1 / 5  N26 Inc. ​January 2020 

 
  
Merchandise / Service Not Received 

Please describe your dispute  : 

 
Please attach all of the following:  
Evidence of communication 
with the merchant. 
Evidence of the goods/services purchased. 
Evidence of the delivery date. 
Further details in the commentary field. 
 
 

Merchandise / Services Not As Described 

Please describe how the merchandise  : 

/ service received differs to the 
merchandise / service purchased 
 
Please attach all of the following:  
Evidence of communication 
with the merchant. 
Evidence of the goods/services purchased. 
Evidence of expected delivery date. 
Evidence of/description of why the goods 
were not as described.  
Further details in the commentary field. 
 
 

Cancellation of a recurring transaction 

Please confirm the following: 

Were you advised of the  ​YES  ​NO 

cancellation policy? 

Please explain the cancellation policy  : 

     
Form: ​Statement of Consumer Dispute  2 / 5  N26 Inc. ​January 2020 

 
  

What date did you cancel?   : 

How did you cancel?  Phone/Email/Other (please specify) :  

 
 

Please describe your situation  : 

 
   
Please attach all of the following:    
 
● Evidence of communication with the   
merchant   
● Evidence of the goods/services paid for    
● Evidence of the cancellation date   
● Further details in the commentary field    
 
   
 

Cancellation of a reservation 

Please confirm the following: 

Were you advised of the  ​YES  ​NO 

cancellation policy? 

Please explain the cancellation policy  : 

What date did you cancel?   : 

How did you cancel?  Phone/Email/Other (please specify) :  

 
 

Please describe your situation  : 

 
   
Please attach all of the following:    
 
● Evidence of communication with the   
merchant   
● Evidence of the goods/services paid for    
● Evidence of the cancellation date   
● Further details in the commentary field    
 
   
 

     
Form: ​Statement of Consumer Dispute  3 / 5  N26 Inc. ​January 2020 

 
  
Refund / Credit Not Received 

Please describe your dispute  : 

 
Please attach all of the following:  
Evidence of communication with the 
merchant 
Evidence of the credit receipt/invoice 
which states the refund on your card 
Further details in the commentary field  
 
 

Paid by Other Means 

Please describe your dispute  : 

 
Please attach evidence that you paid with one 
of the following: 
Check 
Cash 
Another credit/debit card 
Voucher 
Other (please specify): 
 
_______________________________________ 

Duplicate Processing 

Please describe your dispute  : 

 
Please attach all of the following: 
Evidence of communication with merchant 
Further details in the commentary field 
 

     
Form: ​Statement of Consumer Dispute  4 / 5  N26 Inc. ​January 2020 

 
  
 

Additional Information​ ​Please describe the incident further in the box below: 

 
 
Section Three – Signature and Identification 
1. I am attaching a selfie holding the ID next to my face. My ID is (please select one): 
☐ Driver's license 
☐ Passport 
☐ Any other form of government official ID, please specify: 

_____________________________________________________________________________ 

2. I will, unsolicitedly and immediately, inform N26 Inc. about any refund payments of the disputed 
amount by a third party. I hereby declare that all information is complete and truthful. 

Signature:  Date: 
 

     
Form: ​Statement of Consumer Dispute  5 / 5  N26 Inc. ​January 2020